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Sunday, November 25, 2007

Creating a Foundation

Today's post lays a stone in the foundation of this site with a review of a journal article about modulation and visual attention. My comments follow the article summary.Article review: Liss, M., Saulnier, D.F., & Kinsbourne, M. (2006). Sensory and attention abnormalities in autistic spectrum disorders. Autism, 10, 155-172.

I read the article by Liss, et al. this afternoon. The authors conducted a large study looking for patterns in modulation, overselective attention and exceptional memory in children with autism. They hypothesized that sensory overreactivity is a response to over-arousal. They expected to see that children with sensory overreactivity will additionally show these attributes: not being able to quickly shift attention, perseveration due to unshifting attention and exceptional memory for "self-selected material". In a population of 144 children with autism, 12% of the children did indeed exhibit a correlation of these behaviors. These children tended to be older (11 years) than the average age in the study (8.5 years) and higher functioning, but with poor social skills. The authors divided the 144 children into 4 clusters based on scores (from many tests).

Cluster 1: (12%) labeled, "Overfocused". The children displayed sensory overreactivity inability to quickly shift attention, perseveration due to unshifted attention and exceptional memory for "self-selected material". They demonstrated poor social and imitative play skills and showed the best fit to the DSM-IV definition of autism. They also displayed the least impairment of receptive and expressive communication skills, but the highest functioning level. They also demonstrated sensory seeking behaviors.Cluster 2: The second cluster (25%) was labeled "No sensory problems" and was relatively high functioning with few functional issues.Cluster 3: (30%), labeled "Low functioning". These children registered low in adaptive functioning, high in underreactivity and also in sensory seeking. They had poor social skills and poor receptive and expressive communication skills.Cluster4: (33%) "Mildly overfocused", was quite similar to cluster 1 but higher functioning and only mildly over-focusing.

Cluster 1 had social skills equally impaired as cluster 3.

There was a lengthy and interesting discussion section. Here are some highlights:1. Cluster 1's sensory seeking behaviors might be explained as a way for them to create soothing stimuli in the face of noxious sensory input.2. Kinsbourne is cited in an earlier article (1991) as saying that the overfocused subgroup represents a "dimension of personality that extends the continuum of autistic behavior into normality". That is, it is also found in normally functioning individuals without autism.3. Hussman (2000) described over-arousal as occurring due to noise in the cortex. Normal sensory input must compete with this noise and causes overreactivity.4. Finally, the authors suggest that overselective attention and perseverative behaviors help an individual to create predictable and repetitive events for themselves as a way of moderating over-arousal. This group had the oldest mean age - a little less than 12.

Thoughts on unshifting attention:Given that there is a continuum in shifting attention to unshifting attention, how long does it take the average person to shift thoughts? What is the reason that others shift more slowly? Are they absorbed in thought? Are they emotionally engaged? Are they enjoying sensations?

The authors said that the condition of overfocused attention occurs in the typical population - presumably scholars and meditators are among this group. The ability to shift attention will probably vary according to how deeply enmeshed in thought a person is as well as to cognitive function.

1. Emotional shifting: I have a friend, Kate, who needs 20 minutes to return to her normal state after seeing a scary film. You can't talk to her about anything during that time because she is reactive. Kate says that she is still emotionally involved in what she saw. It seems that Kate is over-aroused by the events in the film and then over engages with the emotional content and then overreacts (by not being able to return to normalcy) in turn -- just as Liss, et al., suggest happens in clusters 1 & 3 above. (Does she also have an excellent memory for emotional content? Good question!) Kate tells me that she tends to read books with predictable stories. Her hobbies are solitary: solving puzzles, work on her house and crafts. Kate is an example of a person with poor modulation of emotional input. She is able to lead a normal life by limiting emotional input.

2. Activity shifting: Children with autism have difficulty moving from one activity to another unless they are given time to adjust to the change. Likewise, they often overreact to loud noises or disruptions. There are a number of techniques used to help them with transitioning from one activity to another in a classroom setting - the chief being to follow a schedule (be it a picture schedule or a written schedule). However, on-the-spot interruptions are hard for them and can cause meltdowns. I work with a boy (Lonnie) who will not work in therapy unless he follows a schedule - and then he is quite compliant. I have begun the process of unstructuring the schedule. I create a written schedule (a list of numbered activities) and then beside the list write other possible (alternate) activities. Part way through our therapy session, I substitute an alternate activity for the next thing planned. I put it on the list, and Lonnie does it without complaint. He is able to shift within just a few seconds that way. He has been given warning, even though it was not highly structured. My next step with him is to make an unordered list of activities. I think that he is ready to follow it.

3. Sensory shifting: When kids seek sensory stimulation (swinging, visual perseveration, crashing against things), they can have difficulty pulling away. They are getting input that they apparently need (or so our sensory integration (SI) literature tells us). They are presumably calming themselves (i.e. self-regulating!). For some reason it takes a while for them to do so. Think of Kate and her slow movement out of an intense place and back into the real world. The SI theory states that if we can finally satiate the sensory need, the seeking will abate ... and this is true for many of the kids I treat. (Amazing to see, actually!)

4. Habit/addiction/compulsion: Other topics that comes to mind are addiction and compulsion. So many people are addicted to video games. We exhibit seeking behaviors when we do it ... however, it is not input that is necessarily good for us (certainly not when it interferes with our life, or with having a life). Worse, not all of us are able to finally become satiated and get back to our lives.

5. Cognitive shifting: I think that all of the above topics fall also fall under the heading of cognitive shifting, with habit and addiction being the most relevant.

It's all here. My friend Kate appears to demonstrate a similar pattern to clusters 1 & 4. She is not and never was autistic, but she certainly is able to focus deeply (is forced to due to over-arousal). Is she on the continuum of behaviors that eventually become described as autism? Probably. I read recently that we tend to over diagnose autism (and ADHD) in kindergarten. Not all kids are equally social - and teachers become worried by those who are more solitary. Perhaps those children grow up to become Kate or a skate-boarder (Sensory seeking), a habitual video game user or a gambler. When we fail to learn to modulate our inner and outer experiences, we fail to develop habits that allow us to find peace within ourselves - and this is all at the expense of typical social interaction.